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Congenital Diaphragmatic Hernia with Partial Gastric Volvulus Simulating As Pneumothorax

Bilal Mirza, Muhammad Saleem

Department of Pediatric Surgery, The Children’s Hospital and the Institute of Child Health Lahore, Pakistan

 

Correspondence

Bilal Mirza

Department of Pediatric Surgery

The Children’s Hospital and the Institute of Child Health Lahore

Pakistan

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Abstract

Late presenting congenital diaphragmatic hernia may have varied clinical presentations which often simulate other entities. We encountered an infant with severe respiratory distress of sudden onset. It was initially thought of as tension pneumothorax; further events revealed it as congenital diaphragmatic hernia with partial gastric volvulus leading to gastrothorax which simulated as tension pneumothorax. Patient underwent surgery and repair of posterolateral congenital diaphragmatic hernia with a good postoperative outcome.

Keywords: congenital diaphragmatic hernia, gastric volvulus, pneumothorax, thoracentesis

 

Introduction

Congenital diaphragmatic hernia usually presents in early days of life with respiratory distress. Rarely, it may escape early presentation and diagnose in childhood or adulthood. Late presentations of CDH are quite challenging as to exact diagnosis thus leading to misdiagnosis and delayed treatment [1, 2]. We, herein, report an infant with CDH that simulated as tension pneumothorax.

Case Report

A 5-month-old female infant presented in medical emergency with severe respiratory distress of sudden onset. There was no history of fever, cough, or vomiting. General physical examination showed afebrile child with tachypnea and respiratory distress. Pulse was 115/min and respiratory rate was 50/min. oxygen saturation on pulse oximetry was 75% with respiratory acidosis on arterial blood gas analysis. Chest auscultation revealed, reduced air entry on left side of the chest. Chest x-ray performed gave suspicion of tension pneumothorax with mediastinal shifting (Fig. 1).

Figure 1: Chest x-ray simulating pneumothorax.

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A chest tube was passed on left side, however, no air evacuated by the drain instead few milliliters of pleural fluid was drained. There was no improvement in respiratory distress. A repeat chest x-ray gave suspicion of eventration of left hemidiaphragm with gastrothorax. Immediately a large bore well lubricated nasogastric tube was passed which resulted in drainage of air and 200ml gastric aspirate. This was followed by alleviation of respiratory distress and oxygen saturation became 100% on pulse oximetry. The ABG’s also normalized after few hours. Repeat chest X-ray confirmed nasogastric tube in the chest with relieved mediastinal shifting (Fig. 2).

Figure 2: Chest x-ray after passage of NG tube which decompressed herniated gastrothorax.

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The patient underwent laparotomy which showed gastrothorax with partial gastric volvulus through a postero-lateral defect in the left hemidiaphragm (Fig. 3). Spleen and a part of colon were also present in the epigastrium near the diaphragmatic defect but not really herniated into the chest. The stomach was delivered back to the abdomen and diaphragmatic defect was repaired after mobilizing margins of the diaphragm. Fortunately, the chest intubation had not injured stomach. The postoperative recovery was uneventful until second postoperative day when the patient again developed respiratory distress. Chest x-ray showed right sided collapse of the lung which was managed with nebulization with steam and N-acetylcystine, and chest physiotherapy. The patient was discharged on 12th postoperative day in satisfactory condition. The patient is doing fine on follow-up.

Figure 3: Postero-lateral defect in the diaphragm.

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Discussion

Late presenting diaphragmatic hernia has been reported to simulate a number of conditions including tension pneumothorax, pleural effusion, pneumonia, chest mass, congenital cystic adenomatoid malformation, and so on [1-6]. In case when the tension pneumothorax is suspected, the consequent tube thoracostomy not only delays the treatment but often results in iatrogenic injuries to the herniate viscera [5].

As the diaphragmatic defect in our case was congenital one and abdominal viscera especially stomach used to herniate into the chest since birth, but a partial volvulus of the stomach resulted in entrapment of air and feed into the stomach thus leading to rapid increase the size of gastrothorax that simulated as pneumothorax. Secondary gastric volvulus has been reported to occur especially with diaphragmatic anatomic defects [7] as happened in the index case where CDH resulted in secondary partial gastric volvulus that led to sudden respiratory distress without preceding history of any fever, cough, and vomiting that if present could support pneumothorax secondary to respiratory tract infection.

Left-sided suspected pneumothorax not relieved by chest intubation needs nasogastric tube for ruling out or decompressing presumptive gastrothorax. We believe that a partial gastric volvulus must always be present for entrapment of air and feed in the stomach that ultimately shifts mediastinum and mimics tension pneumothorax. Presence of spleen in the epigastrium or anterior to the stomach in case of CDH and gastrothorax may indicate some sort of gastric twist around its long axis. Presence of NG tube in the thorax on plain x-ray, contrast meal and follow through revealing alimentary tract in the thorax, and CT scan/MRI aid in the ultimate diagnosis [2].

Initial treatment is passage of well lubricated NG tube to decompress stomach and relieve respiratory compromise [1]. It is our observation that a wide bore well lubricated NG need to be adjusted as small size NG tube may not pass due to acute angle of the esophagus at cardiac end at the brim of the diaphragmatic defect and also associated partial twisting of the stomach make it difficult for small size NG to negotiate gastro-esophageal junction. This is followed by surgical intervention in the form of retrieval of herniated viscera and repair of the diaphragmatic defect with or without mesh placement [1-5]. In our case, the defect was closed very easily without need of a prosthetic mesh.

In summary, late presenting CDH have myriad of presentations. Tension pneumothorax is often simulated in case of gastrothorax with presence of partial gastric volvulus. Passage of NG tube may decompress the stomach however care should be taken not to delay chest intubation in case of true tension pneumothorax.

 

 

 

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